Infectious XDR-TB patients being sent home

Cape Town - Patients with extreme drug-resistant (XDR) tuberculosis are being sent home while still infectious because there are not enough beds in TB hospitals and there is a scarcity of community-based palliative care centres.

A UCT study revealed that a third of discharged XDR patients had positive sputum cultures. They had not responded to medicine and had no other treatment options.

The study followed more than 100 XDR patients from three hospitals - Brooklyn Chest Hospital in Cape Town, Gordonia Hospital in Upington and Sizwe Tropical Disease Hospital in Joburg - between 2008 and 2012. Only 16 percent of patients completed treatment or were cured and the rest either did not take their medicine, failed to respond to treatment or died before completing treatment.

Out of the 107 patients followed during the first two years, 49 patients (46 percent) died, 7 percent defaulted and 23 percent failed treatment despite a lengthy treatment of about eight anti-TB antibiotics.

After five years of treatment only 11 percent of patients had a favourable outcome, 73 percent died and 10 percent failed treatment.

The failure to respond to treatment raised fears that patients had developed total drug-resistant TB, which is on the increase in places such as India, Italy, Iran and Eastern Europe.

Further, these results raise the spectre of drug-resistant TB spreading in South Africa - already one of the countries worst affected by TB.

There are about 500 000 new cases of TB every year and about 1 000 people in every 100 000 live with the disease. Out of the half a million cases more than 15 000 are infected with multidrug-resistant (MDR) TB - a resistance to the standard TB drugs used for treatment. Of the 15 000, about 8 percent are resistant to second-line drugs and have XDR, which has only a 13 percent cure rate in South Africa.

The country had not seen totally drug-resistant TB until last year when 17 cases were identified in the Eastern Cape. These cases made South Africa the fourth country to report this strain of TB. It was discovered in India two years ago, in Italy in 2003 and in Iran in 2009.

In the UCT study, out of the 45 patients who were discharged and sent home, only 58 percent had converted sputum to negative or a non-infectious stage. The remaining 42 percent of XDR patients remained highly infectious, putting those around them at risk.

Presenting the results of the study at the 16th International Congress on Infectious Diseases in Cape Town last week, Keertan Dheda, co-author of the study and professor of medicine at UCT, said newer TB drugs were required if the war against drug-resistant TB was to be won.

In the absence of these drugs - such as bedaquiline which was not yet approved in South Africa - TB prophylaxis or linezolid should be introduced.

He said there was “an urgent need” to link home-based care with palliative care and have community-based facilities where patients could stay to reduce transmission of the disease.